Hysterectomies and C-sections are two of the most overused surgeries. One in three women has a hysterectomy by age 60 and about half eventually have one. Approximately 600,000 women undergo hysterectomy annually, 50,000 to 60,000 of which are for a cancer diagnosis. This graph (figure B) depicts the number done for cancer (which are typically done as inpatient). However, the graph misrepresents total hysterectomies as it depicts only inpatient figures. In 2014, 70% of hysterectomies were done as outpatient – in ambulatory surgery centers or in hospitals with discharge in less than 24 hours. So one could say that ~90% of the ~600,000 are unnecessary. ACOG says that 76% do not meet ACOG criteria.
The Greed Factor
What is driving the high rate of hysterectomies? The more cynical among us would argue that money or greed is a large contributing factor and there are certainly data to back this up. In this article, a gynecologist talks about attending a seminar where gynecologists were coached on how to cultivate patients for hysterectomy to maximize fees. The healthcare dollars wasted on unnecessary medical procedures, especially hysterectomy at $17B, is discussed here. Another factor contributing to this gross overuse is the failure to properly diagnose and inform patients of treatment options and their risks and benefits. This failure may also be due, at least in part, to greed.
Ignorance at Play?
Still yet another variable may be at play: ignorance. For whatever reason, there is a huge disconnect between the perceived benign nature of the procedure and its reality. The research here, here and here are just a few examples of the compelling evidence of the damaging effects. These effects are affirmed by the thousands of comments on the various hysterectomy articles on this blog and others.
A Gynecologist’s Defense of Hysterectomy
A comment by a gynecologist on one of my articles reflects the ignorance and arrogance regarding the many aftereffects of hysterectomy (with or without ovary removal / castration).
Here is the May 3, 2018 comment by gynecologist Yvonne Treece, MD, FACOG:
There is no or minimal evidence to support many of these claims particularly in regards to pelvic ligaments providing support to the entire torso, loss of sensation, loss of sexual pleasure, fatigue, joint and ligament pain. There is some risk of nerve damage, but it is very small and does not result in loss of sensation over the whole vulva and vagina. There is a small risk of damage to bowel or bladder, with the ureters at highest risk. The percentages given in the YouTube video are grossly exaggerated, and most have no proven correlation with hysterectomy. The uterosacral ligaments are preserved in supracervical and most laparoscopic hysterectomies. The vast, vast majority of hysterectomies are uncomplicated. Most of the YouTube video is false. The false and misleading information is a disservice to patients. Where is the evidence for these claims?
I disagree that 70-90% of hysterectomies are unnecessary. Source? As alternative treatments become available, hysterectomy rates are falling. I am an OB/Gyn, and certainly do not do unnecessary hysterectomies, especially not for profit! That is a very hurtful, and malicious thing to say. It is not true of any one I know. Certainly someone may be performing unnecessary surgery for profit, but that is highly unethical, and illegal. Not mainstream.
Please look at an anatomy book (like the slides on the YouTube videos). A lot of your claims are physiologically nonsensical. It makes me sad that people have bad outcomes sometimes, but it saddens and frustrates me when patients are given misinformation attributing physical symptoms to a hysterectomy when they are unrelated.
I would be happy to have a dialogue with you about hysterectomy. I’m sure we could both learn from each other.
Here is my rebuttal comment:
Yvonne – As a doctor in a specialty (gynecology) whose training and livelihood is entrenched in doing hysterectomies (as well as oophorectomies), it’s natural to deny and defend. I don’t know how much of your misinformation is due to lack of proper medical training (including intentional omission by medical schools) and how much is in defense of your profession and livelihood. But regardless, I will address your points:
1) The severing of the ligaments that run from the uterus to the pelvic wall cause a collapse of the torso. It’s an anatomical fact. To use an analogy – If you cut through bridge supports, the bridge will collapse. A woman can still be “fit” after a hysterectomy but her figure / skeletal structure will be altered. Her midsection will gradually shorten and thicken (even absent weight gain). Women’s comments corroborate this. Further evidence of this can be seen as an indentation at each side of her back (one woman referred to it as a “plane” across her back) where her rib cage is now sitting on her hip bones. Another telltale sign is a crease / line that starts a couple inches above the navel and then gradually lengthens across her midsection as her rib cage drops. I doubt you typically observe patients before their surgeries and a few years after in their underwear to be able to observe these changes. And it seems many women end their relationships with their surgeons. They certainly don’t need birth control or any other reproductive services.
2) Another anatomical fact – The uterus separates and anchors the bladder and bowel. Its removal displaces them increasing risk for dysfunction in the short and long-term including incontinence and prolapse. With so many women having had hysterectomies, it’s no wonder incontinence is so prevalent.
3) Another anatomical fact – A shortened and sutured shut vagina lacks the bundle of nerves at the bottom of the cervix as well as the tip of the cervix that heightens sexual pleasure for both the woman and man.
4) How can you truly believe that severing of nerves and blood vessels, including those running through ligaments that are severed, does not cause loss of sensation and sexual pleasure? It is basic physiology that innervation and blood flow are vital to sensation. Many women even report loss of nipple sensation. And furthermore, uterine orgasms cannot physically happen without a uterus. This is a HUGE loss for many women. And many women who still have ovaries (the lucky ones whose ovaries haven’t “died” due to loss of blood flow and feedback with the uterus) report loss of libido and sexual function. There are PLENTY of women’s stories of shattered lives on the web if you really care to know.
5) Most hysterectomies may be (in your words) uncomplicated (absent the “surgical” errors of ureter, bladder, bowel damage, nerve damage, blood clots, hemorrhage, infection, morcellated / upstaged tumors, anesthesia harms, death). But the after effects are forever (as are the after effects of some complications when they occur). And shockingly, 55% of hysterectomies include removal of ovary(ies) (equivalent of a man’s testicles) despite the average woman’s lifetime risk of ovarian cancer being a measly 1.3%. More ovaries are removed as separate surgeries.
6) According to Obstetrics & Gynecology August 2013, ~50,000 hysterectomies are done for cancer. That is less than 10% of all hysterectomies making over 90% unnecessary. Media reports of declining hysterectomy rates are misleading in that they typically report only inpatient hysterectomies and the large majority are now done outpatient / ambulatory as I’m sure you’re aware. In 2014, 70% of commercially insured hysterectomies were outpatient.
7) I’m concerned that you also fail to inform your patients of the many increased health risks associated with hysterectomy (with ovarian “conservation”) – cardiovascular disease (3-fold), metabolic syndrome, increased Body Mass Index, increased BP, renal cell cancer, colorectal cancer, thyroid cancer. Ovary removal (castration) or post-hysterectomy ovarian failure is also common and is associated with another whole list of health risks such as cardiovascular disease (7-fold), stroke, lung cancer, osteoporosis, hip fracture, dementia, parkinsonism, impaired cognition and memory, mood disorders, adverse ocular and skin changes, sleep disorders, more severe hot flushes. Even unilateral oophorectomy (with or without hysterectomy) is associated with increased risk of cognitive impairment, dementia and parkinsonism.
Needing CME credits? You may have just earned some although you should have already known all of the above since this is your specialty.
Let the women who have had unnecessary hysterectomies (and those who love them) decide who is doing a “disservice to patients.”
Alternatives to hysterectomy are great but some of those also cause permanent harm. Ablation has been shown to increase risk of hysterectomy due to Post Ablation Syndrome. The blood can get trapped in the uterus (behind the scarred lining or due to a stenotic cervix) and/or back up into the tubes causing chronic and debilitating pelvic pain. Although procedures are the money makers, they should only be used as a last resort especially when they can do more harm than good. That applies to any specialty.
You said you “certainly do not do unnecessary hysterectomies, especially not for profit!” You mentioned you’re an ob/gyn so I assume not a gynecologic oncologist. In that case, all hysterectomies you do should be for benign conditions which makes them unnecessary.
If “performing unnecessary surgery for profit” is not “mainstream” then how do you explain the high rate of hysterectomies when less than 10% are done for cancer? And why do residents have to do so many hysterectomies yet ZERO myomectomies when many hysterectomies are done for fibroids? Yes, it’s very unethical but it’s the “standard of care” so it continues.
It’s no surprise that she did not respond to my rebuttal even though she stated “I would be happy to have a dialogue with you about hysterectomy.”
It Comes Down to Money
Gynecologists are supposed to be the experts on female anatomy and physiology. There is an abundance of medical literature on the harms of female organ removal. So how can they not know the consequences of removing the uterus and/or ovaries? As Upton Sinclair said:
“It is difficult to get a man to understand something when his salary depends on his not understanding it.”
You can read all my articles about three of gynecology’s destructive procedures – hysterectomy, oophorectomy, endometrial ablation – here. They include citations to medical literature.
For the truth about female anatomy and the lifelong functions of the female organs, check out this video:
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